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Health Center:

Pharmacy:

Capture Date :

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			Health Center	Pharmacy	ShipTo	Claim Type	RX Number	Member ID	Fill	Fill Date	Adjud Date	Captured Date	NDC	Drug Name	Strength	Form	Pkg Size	QTY Disp	Curr QTY	% of Claim	Status	Status Date	Order	Wholesaler Invoice
False	8945438		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796959	MR00145031	00	03/27/2023	03/27/2023	03/28/2023	45802014167	CICLOPIROX 8% SOLUTION	8 %	SOLUTION	6.6	6.6	6.6	100.00000	Replenished		1002195747	3128183260